Transcript PSYCHOSOCIAL EVALUATION AND TREATMENT IN CHRONIC

PSYCHOSOCIAL
EVALUATION AND
TREATMENT IN CHRONIC
RESPIRATORY DISEASES
Prof Behcet Coşar M.D.
Gazi Uni. School of Med. Psychiatry Dep
Consultation Liaison Psychiatry Unit
HUMAN
• Bio
• Psycho
• Social
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 COPD is a severe and treatment
resistant pulmonary disease with varying
impact on the patients’
 general physical condition,
 functioning
 quality of life.
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 The association between chronic
respiratory disorders and psychiatric
disorders, in particular generalized
anxiety, panic anxiety and depression,
has been acknowledged for many years.
 The prevalence of psychiatric
comorbidity in these patients as well as
the effect of treatment and the
prognosis ???????
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 There is evidence that psychiatric
comorbidity contributes significantly to
the functional impairment of COPD
patients
 Psychiatric treatment may improve not
only psychiatric status but also
pulmonary function
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• Patients react emotionally to the
discomfort of dyspnea, the loss of
functional capacity and the threat of
suffocation and death.
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• Dyspnea, like pain is subjective, clearly
influenced by emotional and psychiatric
factors
• Dyspnea may be felt as a sensation of
suffocation and is overwhelmingly
frightening.
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MAIN PSYCHIATRIC
FINDINGS
• Depression
• Anxiety and panic
• Sexual dysfunction
• Cognitive impairment
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Depression
• Depression can range from a
• Mild dysthymia
• Adjustment disorder with depressed
mood
• to a major depressive episode.
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Anxiety and Panic
• Panic disorder, subsyndromal panic and
expectation anxiety often accompanies
the respiratory symptoms
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Sexual Dysfunction and Cognitive
Impairment
• Inhibited sexual excitement
• Inhibited orgasm
• Premature ejeculation
• Cognitive impairment generally in
geriatric patients
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Sexual
dysfunction
Cognitive
impairment
Depression
Depressed
mood
Loss of
interest
Fatigue
Weight
loos/gain
Muscle
tension
Shortness of
breath
Sleep disturb.
Chronic worry
Agitation
Palpitations
Irritability
Nausea
Hopelessness
Difficulty
concentrating
Numbness
Low selfesteem
Thoughts of
death
Motor
retardation
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Anxiety
Fear of
loosing
control
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Importance of Psychiatric
Symptomatology (I)
• Patients with stable chronic obstructive
pulmonary disease (COPD) who show
significant signs of depression may also have
an increased risk of mortality
• COPD patients with depressive symptoms
have a significantly higher risk for
exacerbations.
 Neuropsychological dysfunction is generally
evident in problem-solving deficits
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Importance of Psychiatric
Symptomatology (II)
• Impaired quality of life and restricted
activities of daily living
• Cognitive deficits;
a) difficulty in monitoring the
intensity of their symptoms
b) reduced adherence to their
medications
c) poor quality of life
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Early secreening and
diagnosis!!!!!!!!
•
•
•
•
How????????
Mini Mental Status Examination
Hospital Anxiety and Depression Scale
Clinical interview according to DSM IVTR
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PSYCHOSOCIAL EVALUATION
• A thorough assessment of both the
patients and the family to determine
whether teher are specific
psychodynamic conflicts, behavioral
triggers, or environmental issues that
contribute to exacerbation of the
respiratory illness
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PSYCHOSOCIAL EVALUATION
I
• Asthma have been proposed to have a
significant psychosomatic component
• Some somatic complaints may result
from behavioral conditioning
• Clasically its known that separation
anxiety triggers the asthmatic attacks.
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PSYCHOSOCIAL EVALUATION
II
• Developmental life stage during which the patient develops
respiratory disease is important
• Children with severe respiratory disease
• percieved and treated differently by family and friends
• significant alterations in the relationship with mother
• later susceptibility to the trauma of seperation or other
psychological impairments
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PSYCHOSOCIAL EVALUATION
III
• Experience of fear of drowning
+
• Frequent trips to the emergency room
•
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Pervasive anxiety
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PSYCHOSOCIAL EVALUATION
IV
• Middle aged or old aged patients
• Long-standing plans disturbs
• May results with depression
• High risk of suicide and anxiety
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PSYCHOSOCIAL EVALUATION
V
• COPD patients restricts both activating
(anger / anxiety) and nonactivating
(depression / withdrawal) affects to
avoid the experience of dyspnea.
• A “personality trait” may result from
behavioral reactions to the illness,
rather than be a cause of illness
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SOCIAL COGNITIVE THEORY
• Perceived self-efficacy is a persons’ appraisal
of his or her ability to perform effectively or
completely in a designated situation
• A strong sense of self-efficacy is necessary
for a sense of personal well-being
• Allows for persevering in efforts toward
success
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SOCIAL COGNITIVE THEORY I
•
Self-efficacy expectations vary on 3 dimensions that have an important
effect on performance
•
1) Magnitude: Level of difficulty of the task. Some individuals may feel
capable of performing only simple tasks (i.e., low-magnitude
expectations), whereas others have feelings or competency about
performing complex tasks (i.e., high-magnitude expectation).
•
2) Generality: The extent that a domain of behaviour can be
generalized to other situations. For example, if patients with COPD are
successfully in performing an activity (such as stair climbing) when
supervised, they may anticipate being successful when performing the
activity unsupervised.
•
3) Strength: The confidence individuals have in the accomplishment of a
specific task
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SOCIAL COGNITIVE THEORY
II
• The objectives of structured education
can be formed to increase expectations
of self-efficacy thereby assisting
patients in their efforts to manage, or
avoid, breathing difficulty while
engaging in certain activities.
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SOCIAL COGNITIVE THEORY
III
• Self-efficacy is enhanced or influenced
by four different mechanisms.
• 1) Mastery experience
• 2) Modelling
• 3) Social persuasion
• 4) Judgement of bodily states.
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EDUCATION
•
•
•
•
Illness
Drugs
Apparatus
.......
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THE TRANSTHEORETICAL
MODEL (TTM)
• Used to describe the dynamic process
by which individuals come to adopt and
maintain changes in health behaviors.
• This model asserts that individuals move
through five stages of motivational
readiness for exercise adoption
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TTM-I
A
Precontemplation: Not currently active and not intending to
increase physical activity
1
Discuss the harmful effects of the patient’s inactivity
2
If patient attempted physical activity in the past but was
unsuccessful, problem – solve reasons that led the patient to
resume a sedentary lifestyle
3
Discuss ways in which the patient’s inactivity affects his or her
family and friends
4
Encourage patient to read and think about the benefits of
physical activity for him or her
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TTM-II
B
Contemplation: Not currently active but intending to be more
active in the next 6 months
1
Discuss the benefits of physical activity for the patient
2
Encourage patient to read and think about the benefits of
physical activity
3
Problem-solve ways to decrease the patient’s perceived
barriers of physical activity (e.g nor enough time, fear of
injury, no energy etc.)
4
Encourage patient to set short – term activity goals (one 5minute walk over the next week)
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C
TTM-III
Preparation: Occasionally active but not on a regular basis
1
Problem-solve ways to decrease barriers to more regular exercise
2
Help patient to set short-term activity goals
3
Intruct patient to provide himself / herself with rewards for meeting
activity goals
4
Discuss ways to substitute more active leisure pursuits for sedentary
ones ( e.g., take a short walk after dinner rather than watch TV)
5
Ask patient to post reminders to become more active around his or
her office / home
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TTM-IV
D
Action: Regularly meeting suggested physical activity criterion
for less than 6 months
1
Schedule follow-up visits for physical activity
2
Provide social support by asking how exercise is going; praise
patient for his or her success
3
Help patient plan for times of inactivity (e.g., sickness,
vacation, increased work demand, bad weather)
4
Encourage patient to try alternative forms of activity to
prevent boredom and burnout
5
Instruct patient to provide himself / herself with rewards for
meeting activity goals
6
Ask patient to post reminders to become more active around his or
her office / home
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TTM-V
E
Maintenance: Regularly meeting suggested physical activity
criteria for 6 months or more
1
Schedule follow-up visits for physical activity
2
Continue to provide social support for patient’s activity
3
Help patient develop strategies for self-monitoring his or her
progress
4
Plan for risky situations for inactivity
5
Problem-solve ways to resume activity if relapse occurs (e.g,
avoid all-or-nothing thinking)
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Thank you
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